Why Health Systems Are Walking Away From Medicare Advantage
More than two dozen health systems are leaving Medicare Advantage plans. Why they're going, what it means for your practice and what to check before January.
Which health systems are leaving Medicare Advantage
Every fall, practice administration evaluates whether the practice will remain in its Medicare Advantage plans next year. This year more health systems are leaving Medicare Advantage plans, and patients only have until December 7 to switch. Becker's Hospital Review's running list now has more than two dozen health systems dropping at least one MA plan. Mayo Clinic is out of network with most UnitedHealthcare and Humana MA plans, and UNC Health left Humana, WellCare and HCSC. Sentara Health is preparing to leave Anthem's MA plans in Virginia on January 1 after talks broke down. BJC Health, Saint Luke's and Washington University physicians will be out of network with Aetna MA the same day, and Cleveland Clinic will leave Anthem MA in Ohio unless the two sides reach a deal by December 31.
Why health systems are leaving Medicare Advantage
The systems that give a reason usually point to prior authorization denials, slow payment and documentation demands. KFF found that MA plans made 52.8 million prior authorization decisions in 2024 and denied 7.7% of them. Only 11.5% of those denials were appealed, even though 80.7% of appeals were partly or fully overturned. Most denials are never challenged, and most of the ones that are get overturned. The time consumed either way is onerous, and providers are fed up with it.
MA plans are dropping health systems too
Humana ended its contract with Ohio State's Wexner Medical Center on October 1. Some health systems are getting out of the MA business altogether: Becker's counts at least seven health system-owned insurers leaving MA for 2027, including Providence Health Plan, Memorial Hermann Health Plan and UMass Memorial's Mass Advantage.
What it means for your practice
KFF puts 54% of eligible Medicare beneficiaries in MA in 2025, so these contract decisions reach most practices. If your group is owned by or affiliated with a hospital, you lose participation when the system's contract ends, and that date isn't always January 1. Ohio State's Humana contract ended October 1, and NewYork-Presbyterian's UnitedHealthcare MA contract runs only through October 31 unless they reach a deal. If you're independent and still in network, expect new patients who stayed with their plan and now need a different doctor.
What to do before January
Track denial rate, days to payment and prior authorization volume by MA contract. When a plan comes up for renewal, you want your own numbers, not theirs. Appeal more denials. Keep a list of every MA agreement with its renewal date and notice period. Then, before January 1, check that your providers are credentialed with the plans your patients are moving to, and verify eligibility at every January visit.
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About the author
Tony Kuka · Founder, Ziurta
Tony is the founder of Ziurta, a provider enrollment platform for medical practices, health systems, RCM firms, and credentialing companies. He has 30 years in healthcare administration, including 20 building outsourced revenue cycle companies, and founded and sold Medical Business Office and National Credentialing Solutions. He is based in Chattanooga, Tennessee.